Free Form 2.100.4c - Oregon

IN THE CIRCUIT COURT OF THE STATE OF OREGON FOR THE COUNTY OF _________________ In the Matter of: ) ) ________________________________, ) Petitioner, ) ) and ) ) ________________________________, ) Respondent. )

Case No. ____________________ UTCR 2.100 AFFIDAVIT WITH REQUEST TO SEGREGATE SOCIAL SECURITY NUMBERS ONLY

By this affidavit under UTCR 2.100 and as required by ORS 107.840, I request that the social security number(s) in the attached Segregated Information Sheet be segregated (kept separate) from information that the general public can see. The social security numbers that I request be segregated are as follows: A. Protected Personal Information G Petitioner's Social Security Number G Respondent's Social Security Number G Child/Children's Social Security Number(s), if applicable B. Legal Authority ORS 107.840 ORS 107.840 ORS 107.840

I have mailed or delivered copies of this request (not including the attached information sheet) to the opposing party in this matter. Certificate of Document Preparation. You are required to truthfully complete this certificate regarding the document you are filing with the court. Check all boxes and complete all blanks that apply: G I selected this document for myself and I completed it without paid assistance. G I paid or will pay money to ________________________________ for assistance in preparing this form. I hereby declare that the above statement is true to the best of my knowledge and belief, and that I understand it is made for use as evidence in court and is subject to penalty for perjury. Date: OSB # (if applicable): Signature: Type or Print Name:

Page 1 - Form 2.100.4c ­ AFFIDAVIT WITH REQUEST TO SEGREGATE SOCIAL SECURITY NUMBERS ONLY ­ UTCR 2.100 (Revised 8-1-05)

UTCR App. Page 5